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Clover Health

Clover is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans.

Utilization Management, Registered Nurse (RN)

Location

United States

Posted

35 days ago

Salary

$90K - $106K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Utilization Management, Registered Nurse (RN)

Clover Health

Role Description As a Utilization Management, Registered Nurse (RN), you will: - Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute (SNF, IRF, LTACH) and outpatient services. - Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support determinations. - Manage cases end-to-end from prior authorization through concurrent review and discharge. - Collaborate with providers and facilities to obtain clinical information and support care coordination. - Ensure compliance with CMS turnaround times and regulatory requirements. - Participate in Quality Assurance (QA) activities, including case audits and peer reviews to ensure accuracy and consistency in decision-making. - Have strong personal accountability, responsibility and independent decision-making abilities. Qualifications - You hold a current and valid Compact Registered Nurse (RN) license (required). - You have experience in Utilization Management - Prior Authorization Reviews (required). - You have at least 1 year of experience performing medical necessity reviews using CMS Medicare criteria (required). - You have strong knowledge of CMS guidelines, NCD/LCD and evidence-based criteria (MCG, Interqual). - You are comfortable working in a remote, fast-paced, and data-driven environment with productivity standards. - You have excellent interpersonal skills and ability to communicate with patients and colleagues. Benefits - Financial Well-Being: Competitive base salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews. - Physical Well-Being: Comprehensive medical, dental, and vision coverage. - Mental Well-Being: Initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. - Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews. - Additional Perks: - Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities. - Reimbursement for office setup expenses. - Monthly cell phone & internet stipend. - Remote-first culture, enabling collaboration with global teams. - Paid parental leave for all new parents. - And much more!

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